Mainstreaming adult ADHD into primary care in the UK: guidance, practice, and best practice recommendations.

BACKGROUND: ADHD in adults is a common and debilitating neurodevelopmental mental health condition. Yet, diagnosis, clinical management and monitoring are frequently constrained by scarce resources, low capacity in specialist services and limited awareness or training in both primary and secondary care. As a result, many people with ADHD experience serious barriers in accessing the care they need. METHODS: Professionals across primary, secondary, and tertiary care met to discuss adult ADHD clinical care in the United Kingdom. Discussions identified constraints in service provision, and service delivery models with potential to improve healthcare access and delivery. The group aimed to provide a roadmap for improving access to ADHD treatment, identifying avenues for improving provision under current constraints, and innovating provision in the longer-term. National Institute for Health and Care Excellence (NICE) guidelines were used as a benchmark in discussions. RESULTS: The group identified three interrelated constraints. First, inconsistent interpretation of what constitutes a 'specialist' in the context of delivering ADHD care. Second, restriction of service delivery to limited capacity secondary or tertiary care services. Third, financial limitations or conflicts which reduce capacity and render transfer of care between healthcare sectors difficult. The group recommended the development of ADHD specialism within primary care, along with the transfer of routine and straightforward treatment monitoring to primary care services. Longer term, ADHD care pathways should be brought into line with those for other common mental health disorders, including treatment initiation by appropriately qualified clinicians in primary care, and referral to secondary mental health or tertiary services for more complex cases. Long-term plans in the NHS for more joined up and flexible provision, using a primary care network approach, could invest in developing shared ADHD specialist resources. CONCLUSIONS: The relegation of adult ADHD diagnosis, treatment and monitoring to specialist tertiary and secondary services is at odds with its high prevalence and chronic course. To enable the cost-effective and at-scale access to ADHD treatment that is needed, general adult mental health and primary care must be empowered to play a key role in the delivery of quality services for adults with ADHD.

Prediction of pre-eclampsia in nulliparous women using routinely collected maternal characteristics: a model development and validation study.

BACKGROUND: Guidelines recommend identifying in early pregnancy women at elevated risk of pre-eclampsia. The aim of this study was to develop and validate a pre-eclampsia risk prediction model for nulliparous women attending routine antenatal care "the Western Sydney (WS) model"; and to compare its performance with the National Institute of Health and Care Excellence (NICE) risk factor-list approach for classifying women as high-risk. METHODS: This retrospective cohort study included all nulliparous women who gave birth in three public hospitals in the Western-Sydney-Local-Health-District, Australia 2011-2014. Using births from 2011 to 2012, multivariable logistic regression incorporated established maternal risk factors to develop and internally validate the WS model. The WS model was then externally validated using births from 2013 to 2014, assessing its discrimination and calibration. We fitted the final WS model for all births from 2011 to 2014, and compared its accuracy in predicting pre-eclampsia with the NICE approach. RESULTS: Among 12,395 births to nulliparous women in 2011-2014, there were 293 (2.4%) pre-eclampsia events. The WS model included: maternal age, body mass index, ethnicity, multiple pregnancy, family history of pre-eclampsia, autoimmune disease, chronic hypertension and chronic renal disease. In the validation sample (6201 births), the model c-statistic was 0.70 (95% confidence interval 0.65-0.75). The observed:expected ratio for pre-eclampsia was 0.91, with a Hosmer-Lemeshow goodness-of-fit test p-value of 0.20. In the entire study sample of 12,395 births, 374 (3.0%) women had a WS model-estimated pre-eclampsia risk ≥8%, the pre-specified risk-threshold for considering aspirin prophylaxis. Of these, 54 (14.4%) developed pre-eclampsia (sensitivity 18% (14-23), specificity 97% (97-98)). Using the NICE approach, 1173 (9.5%) women were classified as high-risk, of which 107 (9.1%) developed pre-eclampsia (sensitivity 37% (31-42), specificity 91% (91-92)). The final model showed similar accuracy to the NICE approach when using lower risk-threshold of ≥4% to classify women as high-risk for pre-eclampsia. CONCLUSION: The WS risk model that combines readily-available maternal characteristics achieved modest performance for prediction of pre-eclampsia in nulliparous women. The model did not outperform the NICE approach, but has the advantage of providing individualised absolute risk estimates, to assist with counselling, inform decisions for further testing, and consideration of aspirin prophylaxis.

Review: Transition from children's to adult services: a review of guidelines and protocols for young people with attention deficit hyperactivity disorder in England.

BACKGROUND: In recent years, the difficulty for young people with mental health issues who require a transition to adult services has been highlighted by several studies. In March 2018 the National Institute of Health and Care Excellence (NICE) produced detailed guidelines for the diagnosis and management of attention deficit hyperactivity disorder (ADHD), updated from previous versions in 2008 and 2016, which included general recommendations for transition to an adult service. Yet, there is limited research on transition specifically for those with ADHD. This review aims to systematically identify, review and compare guidelines, specifically focussed on transition for young adults with ADHD within England. METHODS: Following the general principles for systematic reviewing as published by the University of York, 10 electronic databases were searched. Further documents were identified through searches of grey literature and additional sources. RESULTS: Sixteen documents were included. Results indicate very limited publically accessible guidelines in England for transition of young people with ADHD. Nearly all identified documents based their recommendations for transition on the existing NICE guidelines. Neurodevelopmental conditions such as ADHD are often encompassed within one overarching health policy rather than an individual policy for each condition. CONCLUSIONS: Guidelines should be available and accessible to the public in order to inform those experiencing transition; adjusting the guidelines to local service context could also be beneficial and would adhere to the NICE recommendations. Further review could examine transition guideline policies for mental health in general to help identify and improve current practice.

Treatments for bulimia nervosa: a network meta-analysis.

BACKGROUND: Bulimia nervosa (BN) is a severe eating disorder that can be managed using a variety of treatments including pharmacological, psychological, and combination treatments. We aimed to compare their effectiveness and to identify the most effective for the treatment of BN in adults. METHODS: A search was conducted in Embase, Medline, PsycINFO, and Central from their inception to July 2016. Studies were included if they reported on treatments for adults who fulfilled diagnostic criteria for BN. Only randomised controlled trials (RCTs) that examined available psychological, pharmacological, or combination therapies licensed in the UK were included. We conducted a network meta-analysis (NMA) of RCTs. The outcome analysed was full remission at the end of treatment. RESULTS: We identified 21 eligible trials with 1828 participants involving 12 treatments, including wait list. The results of the NMA suggested that individual cognitive behavioural therapy (CBT) (specific to eating disorders) was most effective in achieving remission at the end of treatment compared with wait list (OR 3.89, 95% CrI 1.19-14.02), followed by guided cognitive behavioural self-help (OR 3.81, 95% CrI 1.51-10.90). Inconsistency checks did not identify any significant inconsistency between the direct and indirect evidence. CONCLUSIONS: The analysis suggested that the treatments that are most likely to achieve full remission are individual CBT (specific to eating disorders) and guided cognitive behavioural self-help, although no firm conclusions could be drawn due to the limited evidence base. There is a need for further research on the maintenance of treatment effects and the mediators of treatment outcome.

Modelling the cost-effectiveness of pharmacotherapy compared with cognitive-behavioural therapy and combination therapy for the treatment of moderate to severe depression in the UK.

BACKGROUND: The National Institute of Health and Care Excellence (NICE) in England and Wales recommends the combination of pharmacotherapy and psychotherapy for the treatment of moderate to severe depression. However, the cost-effectiveness analysis on which these recommendations are based has not included psychotherapy as monotherapy as a potential option. For this reason, we aimed to update, augment and refine the existing economic evaluation. METHOD: We constructed a decision analytic model with a 27-month time horizon. We compared pharmacotherapy with cognitive-behavioural therapy (CBT) and combination treatment for moderate to severe depression in secondary care from a healthcare service perspective. We reviewed the literature to identify relevant evidence and, where possible, synthesized evidence from clinical trials in a meta-analysis to inform model parameters. RESULTS: The model suggested that CBT as monotherapy was most likely to be the most cost-effective treatment option above a threshold of £ 22,000 per quality-adjusted life year (QALY). It dominated combination treatment and had an incremental cost-effectiveness ratio of £ 20,039 per QALY compared with pharmacotherapy. There was significant decision uncertainty in the probabilistic and deterministic sensitivity analyses. CONCLUSIONS: Contrary to previous NICE guidance, the results indicated that even for those patients for whom pharmacotherapy is acceptable, CBT as monotherapy may be a cost-effective treatment option. However, this conclusion was based on a limited evidence base, particularly for combination treatment. In addition, this evidence cannot easily be transferred to a primary care setting.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 14.

In this latest update we highlight: a publication from the US FDA regarding the definitions of real-world data (RWD) and real-world evidence (RWE); a publication from academic researchers on a demonstration project for target trial emulation; a publication from the National Institute of Health and Care Excellence (NICE) on the 1 year anniversary of their RWE framework; and a publication from NICE and Flatiron Health on the utility of US RWD for initial UK health technology assessment decision making.

Heart Failure and Cardiac Device Therapy: A Review of Current National Institute of Health and Care Excellence and European Society of Cardiology Guidelines.

Guidelines help clinicians to deliver high-quality care with therapies based on up-to-date evidence. There has been significant progress in the management of heart failure with regards to both medication and cardiac device therapy. These advances have been incorporated into national and international guidelines with varying degrees of success. This article reviews current guidance from the National Institute of Health and Care Excellence in the UK and compares this with European Society of Cardiology guidelines, and evaluates how differences between them may impact on clinical practice.

A review of NICE appraisals of pharmaceuticals 2000-2016 found variation in establishing comparative clinical effectiveness.

OBJECTIVE: To identify and assess the methods for estimating comparative clinical effectiveness for novel pharmaceutical products licensed on the basis of nonrandomized controlled trial (non-RCT) data and to evaluate the corresponding National Institute for Health and Care Excellence (NICE) recommendations. METHODS: Our identification strategy was twofold. First, we reviewed all NICE appraisals between 2010 and 2016 and identified technologies where comparative clinical effectiveness estimates were calculated using non-RCT data. Second, we checked if NICE appraisals completed from 2000 to 2010 had included pharmaceuticals that were granted European Medicines Agency marketing authorization without RCT data between 1999 and 2014. Information was extracted on the method used to establish comparative clinical effectiveness as well as the corresponding NICE recommendations. We also collected information on the rationale for utilizing non-RCT data in NICE appraisals. RESULTS: Of 489 individual pharmaceutical technologies assessed by NICE, 22 (4%) used non-RCT data to estimate comparative clinical effectiveness. Methods for establishing external controls in such studies varied: 13 (59%) used published trials, 6 (27%) used observational data, 2 (9%) used expert opinion, and 1 (5%) used a responder vs nonresponder analysis. Only 5 (23%) used a regression model to adjust for covariates. We did not observe a notable difference in the proportion of pharmaceutical technologies that received a positive recommendation from NICE whether the decision was based on RCT or non-RCT data (83% vs 86%). CONCLUSIONS: To date, a small number of appraisals by NICE based on non-RCT data did not result in substantially different treatment decisions. The majority of the technologies appraised on the basis of non-RCT data either received a positive recommendation or a positive recommendation with restrictions. The methods used to calculate comparative clinical effectiveness estimates varied, highlighting the need to establish clear guidance.

The diagnosis is correct, but National Institute of Health and Care Excellence guidelines are part of the problem not the solution.

Mike Scott's study provides data demonstrating that the national Improving Access to Psychological Therapies project is not leading to improved outcomes or value for money. I present further data from both the adult and children and young people's versions of Improving Access to Psychological Therapies that lends supports to this conclusion. However, while Scott argues in favour of better compliance with National Institute of Health and Care Excellence guidelines and greater model expertise, I argue that it is this 'technical' focus that is part of the problem not the solution.

Transforming Improving Access to Psychological Therapies.

The three commentaries on my paper 'IAPT - The Need for Radical Reform' are agreed that Improving Access to Psychological Therapies cannot be regarded as the 'gold standard' for the delivery of psychological therapy services. Furthermore, they agreed that Improving Access to Psychological Therapies should not continue to mark its 'own homework' and should be subjected to rigorous independent evaluation scrutiny. It is a matter for a public enquiry to ascertain why £1 billion has been spent on Improving Access to Psychological Therapies without any such an independent evaluation. What is interesting is that nocommentary has been forthcoming from the UK Improving Access to Psychological Therapies service nor have they shared a platform to discuss these issues. It is regrettable that the UK Government's National Audit Office has chosen, to date, not to publish its own investigation into the integrity of Improving Access to Psychological Therapies data. Openness would be an excellent starting point for the necessary transformation of Improving Access to Psychological Therapies.

Changing dietary behaviour: the role and development of practitioner communication.

The need to support people to change diet-related behaviour is widely advocated and how to do this effectively in practice is an expanding area of research. Important factors to consider are how healthcare practitioners communicate with their patients and how that communication may affect diet-related behaviour change and subsequent outcomes. The aim of the present paper is to discuss communication skills for behaviour change (CSBC), focusing predominantly on registered dietitians who are required to communicate effectively and have an important role in supporting patients to change diet-related behaviour. The views of dietitians in relation to CSBC have been investigated and respondents have consistently reported that they perceive these skills to be of vital importance in practice. Patient views have reiterated the importance of good CSBC in one-to-one consultations. However, pre-qualification training of dietitians is thought to deliver practitioners who are competent at a minimum level. The need for ongoing continuous professional development (CPD) in relation to CSBC has been recognised but currently most CPD focuses on updating knowledge rather than improving these essential skills. Measuring CSBC in a consistent and objective manner is difficult and an assessment tool, DIET-COMMS, has been developed and validated for this purpose. DIET-COMMS can be used to support CSBC development, but concerns about logistical challenges and acceptability of implementing this in practice have been raised. Although a suitable assessment tool now exists there is a need to develop ways to facilitate assessment of CSBC in practice.